| NPI | 1417947128 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9108902) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: IA 001899) |
| Enumeration Date | 2005-10-25 |
| Last Update Date | 2016-11-15 |