| NPI | 1891958195 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9104033) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 3771) |
| 363AS0400X Physician Assistant Surgical (Licence: FL PA9104033) | |
| Enumeration Date | 2008-07-07 |
| Last Update Date | 2022-02-28 |