| NPI | 1134655152 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9113002) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 12496) |
| 363A00000X Physician Assistant (Licence: FL PA9113002) | |
| Enumeration Date | 2017-05-11 |
| Last Update Date | 2020-12-15 |