| NPI | 1104319300 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9112013) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 022104) |
| 363AS0400X Physician Assistant, Surgical | |
| Enumeration Date | 2018-06-12 |
| Last Update Date | 2022-12-07 |