| NPI | 1619953114 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9103535) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA9103535) |
| Enumeration Date | 2005-12-16 |
| Last Update Date | 2022-08-09 |