| NPI | 1508979550 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: OR 175136) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9102494) |
| 363A00000X Physician Assistant (Licence: VA 0110002969) | |
| Enumeration Date | 2006-08-16 |
| Last Update Date | 2016-05-28 |