| NPI | 1518393131 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: GA 323) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA9107508) |
| 363AM0700X Physician Assistant, Medical (Licence: NC 0010-04468) | |
| Enumeration Date | 2013-09-16 |
| Last Update Date | 2021-01-14 |