| NPI | 1255341996 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9106000) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: VA 0110002063) |
| Enumeration Date | 2006-08-08 |
| Last Update Date | 2020-01-24 |