| NPI | 1912155490 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: FL PA1912155490) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2008-09-08 |
| Last Update Date | 2018-04-23 |