| NPI | 1396966644 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-08289) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9104141) |
| 363AS0400X Physician Assistant, Surgical | |
| Enumeration Date | 2007-05-02 |
| Last Update Date | 2020-10-15 |