| NPI | 1700134640 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9113064) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA08113) |
| 363AS0400X Physician Assistant, Surgical (Licence: FL PA9113064) | |
| Enumeration Date | 2012-08-27 |
| Last Update Date | 2020-04-07 |