| NPI | 1669454104 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MD C0004803) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA3490) |
| 363AS0400X Physician Assistant, Surgical (Licence: FL PA3490) | |
| Enumeration Date | 2005-11-18 |
| Last Update Date | 2018-10-01 |