| NPI | 1477994325 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9117178) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MD A00512) |
| 363A00000X Physician Assistant (Licence: FL PA9117178) | |
| 363A00000X Physician Assistant (Licence: MD C0008128) | |
| 363A00000X Physician Assistant (Licence: GA 9636) | |
| Enumeration Date | 2013-07-08 |
| Last Update Date | 2023-03-08 |