| NPI | 1902359573 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA7877) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9112225) |
| 363AS0400X Physician Assistant, Surgical | |
| Enumeration Date | 2016-07-29 |
| Last Update Date | 2024-01-23 |