| NPI | 1689657066 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: FL PA9103585) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: FL PA9103585) |
| Enumeration Date | 2005-11-21 |
| Last Update Date | 2021-07-19 |