| NPI | 1508427337 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL 9112545) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363AS0400X Physician Assistant, Surgical (Licence: FL PA9112545) | |
| Enumeration Date | 2019-06-24 |
| Last Update Date | 2024-11-14 |