| NPI | 1073575866 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9103967) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO 1498) |
| Enumeration Date | 2006-04-05 |
| Last Update Date | 2007-10-31 |