| NPI | 1316343593 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9108387) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 6203) |
| 363AS0400X Physician Assistant, Surgical (Licence: FL PA9108387) | |
| Enumeration Date | 2014-11-14 |
| Last Update Date | 2026-04-10 |