| NPI | 1689900375 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL 9015099) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: FL 9105099) |
| Enumeration Date | 2009-10-30 |
| Last Update Date | 2015-01-15 |