| NPI | 1699833145 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9112176) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: DE C5-0000477) |
| 363A00000X Physician Assistant (Licence: VA 0110006202) | |
| 363AS0400X Physician Assistant, Surgical (Licence: PA MA002332L) | |
| 363AS0400X Physician Assistant, Surgical (Licence: DE C5-0000477) | |
| Enumeration Date | 2006-12-05 |
| Last Update Date | 2024-01-03 |