| NPI | 1164587978 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9104095) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: FL 9104095) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2006-12-22 |
| Last Update Date | 2012-11-16 |