| NPI | 1629166434 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA3198) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: FL PA0003198) |
| Enumeration Date | 2006-10-10 |
| Last Update Date | 2013-08-28 |