| NPI | 1265615330 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: FL PA9104255) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: FL PA 9104255) |
| Enumeration Date | 2007-12-12 |
| Last Update Date | 2015-07-10 |