| NPI | 1407945256 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA113062) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: FL PA113062) |
| 363AS0400X Physician Assistant, Surgical (Licence: PA ma002553-L) | |
| Enumeration Date | 2006-10-12 |
| Last Update Date | 2020-10-26 |