| NPI | 1780634154 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9101284) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: CO PA.0002382) |
| 363A00000X Physician Assistant (Licence: CO 2382) | |
| Enumeration Date | 2006-05-10 |
| Last Update Date | 2024-01-25 |