| NPI | 1255352605 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NC 102733) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 102733) |
| 363A00000X Physician Assistant (Licence: FL PA9101094) | |
| Enumeration Date | 2006-07-21 |
| Last Update Date | 2023-09-14 |