| NPI | 1649261645 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-06022) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MD COOO2786) |
| 363A00000X Physician Assistant (Licence: FL PA9108044) | |
| 363AS0400X Physician Assistant, Surgical | |
| Enumeration Date | 2005-10-31 |
| Last Update Date | 2015-12-08 |