| NPI | 1093959348 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9104984) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA 9104984) |
| 363AS0400X Physician Assistant, Surgical (Licence: FL PA 9104984) | |
| Enumeration Date | 2009-04-29 |
| Last Update Date | 2021-03-26 |