| NPI | 1912171737 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9104543) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2008-04-14 |
| Last Update Date | 2016-03-16 |