| NPI | 1700852522 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: FL PA9112159) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WA PA10004439) |
| 363A00000X Physician Assistant (Licence: ZZ PA9112159) | |
| Enumeration Date | 2006-02-23 |
| Last Update Date | 2021-02-18 |