| NPI | 1942557178 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: FL PA9107357) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: CT 002789) |
| Enumeration Date | 2012-08-07 |
| Last Update Date | 2013-10-10 |