| NPI | 1174992465 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9108938) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: FL PAT 9108938) |
| 363AS0400X Physician Assistant Surgical (Licence: FL PA 9108938) | |
| Enumeration Date | 2015-09-17 |
| Last Update Date | 2022-12-23 |