| NPI | 1548455660 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: FL PA9101888) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 100638) |
| 363AS0400X Physician Assistant, Surgical (Licence: FL PA9101888) | |
| Enumeration Date | 2007-09-11 |
| Last Update Date | 2023-10-23 |