| NPI | 1598123457 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-06254) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9113430) |
| 363AS0400X Physician Assistant, Surgical (Licence: FL PA9113430) | |
| Enumeration Date | 2016-02-08 |
| Last Update Date | 2024-02-28 |