| NPI | 1154702983 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: AZ 7092) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA9108768) |
| 363AS0400X Physician Assistant, Surgical (Licence: FL PA9108768) | |
| Enumeration Date | 2015-06-17 |
| Last Update Date | 2022-02-25 |