| NPI | 1730627621 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9110121) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA9110121) |
| 363AS0400X Physician Assistant, Surgical (Licence: FL PA9110121) | |
| Enumeration Date | 2017-02-10 |
| Last Update Date | 2017-02-10 |