| NPI | 1528032547 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9102926) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA9102926) |
| Enumeration Date | 2006-02-15 |
| Last Update Date | 2026-10-02 |