| NPI | 1134142151 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-15089) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9104158) |
| 363AS0400X Physician Assistant Surgical (Licence: FL PA9104158) | |
| Enumeration Date | 2006-07-25 |
| Last Update Date | 2025-05-16 |