| NPI | 1255503843 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9104481) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: FL PA9104481) |
| Enumeration Date | 2008-03-24 |
| Last Update Date | 2020-10-09 |