| NPI | 1780658500 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9101733) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9101733) |
| 363AM0700X Physician Assistant, Medical (Licence: FL PA9101733) | |
| Enumeration Date | 2006-02-16 |
| Last Update Date | 2015-11-04 |