| NPI | 1053348490 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9109572) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 10034) |
| 363AS0400X Physician Assistant, Surgical (Licence: AZ 3668) | |
| 363AS0400X Physician Assistant, Surgical | |
| 363A00000X Physician Assistant (Licence: TX PA09406) | |
| Enumeration Date | 2006-06-28 |
| Last Update Date | 2016-09-20 |