| NPI | 1174749212 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: FL PA9111323) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: HI AMD-441) |
| 363AS0400X Physician Assistant Surgical (Licence: MA PA 1619) | |
| Enumeration Date | 2007-04-17 |
| Last Update Date | 2023-01-19 |