| NPI | 1619395241 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-10681) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: FL PAT9107725) |
| Enumeration Date | 2014-04-01 |
| Last Update Date | 2022-01-10 |