| NPI | 1205820206 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9101934) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9101934) |
| Enumeration Date | 2005-09-06 |
| Last Update Date | 2020-08-03 |