| NPI | 1902170327 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: FL PA9106442) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: FL PA9106442) |
| Enumeration Date | 2012-03-02 |
| Last Update Date | 2017-07-07 |