| NPI | 1093715674 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9110158) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MT 371) |
| Enumeration Date | 2005-07-26 |
| Last Update Date | 2022-07-21 |