| NPI | 1013308741 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9109741) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363AS0400X Physician Assistant, Surgical (Licence: MD C05700) | |
| Enumeration Date | 2015-02-17 |
| Last Update Date | 2021-03-16 |