| NPI | 1962467654 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9101954) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9101954) |
| Enumeration Date | 2006-04-18 |
| Last Update Date | 2015-05-13 |