| NPI | 1780893362 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208600000X Surgery (Licence: FL PA9102846) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363AS0400X Physician Assistant, Surgical (Licence: FL PA9102846) | |
| Enumeration Date | 2007-05-21 |
| Last Update Date | 2013-04-25 |