| NPI | 1245540632 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: FL PA9105738) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: FL PA9105738) |
| Enumeration Date | 2010-10-19 |
| Last Update Date | 2015-06-29 |