| NPI | 1497881692 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9104245) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-00772) |
| 363AS0400X Physician Assistant, Surgical (Licence: FL PA91042445) | |
| Enumeration Date | 2007-02-24 |
| Last Update Date | 2016-11-07 |