| NPI | 1205187747 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA 9106832) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: FL PA 9106832) |
| Enumeration Date | 2012-09-24 |
| Last Update Date | 2012-09-24 |