| NPI | 1215574769 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: FL PA9112548) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2019-12-03 |
| Last Update Date | 2022-10-06 |