| NPI | 1649673898 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9108182) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WI 1003) |
| Enumeration Date | 2014-10-02 |
| Last Update Date | 2015-10-20 |