| NPI | 1164804779 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9113946) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: LA 200831) |
| Enumeration Date | 2015-06-19 |
| Last Update Date | 2023-09-13 |