| NPI | 1053313312 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9115249) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AL PA-143) |
| 363AM0700X Physician Assistant, Medical (Licence: FL PA9115249) | |
| 363AS0400X Physician Assistant, Surgical (Licence: AL PA-143) | |
| Enumeration Date | 2005-06-01 |
| Last Update Date | 2023-11-13 |