| NPI | 1154729754 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9108463) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 7347) |
| 363AS0400X Physician Assistant, Surgical | |
| 363AS0400X Physician Assistant, Surgical (Licence: IN 10003781A) | |
| Enumeration Date | 2014-12-12 |
| Last Update Date | 2024-04-11 |