| NPI | 1609866219 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9108734) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: GA 003541) |
| 363A00000X Physician Assistant (Licence: GA 003541) | |
| Enumeration Date | 2005-10-25 |
| Last Update Date | 2022-02-10 |