| NPI | 1194963710 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: FL PA9108767) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WA PA 60058276) |
| 363AS0400X Physician Assistant, Surgical | |
| Enumeration Date | 2009-02-04 |
| Last Update Date | 2021-12-29 |