| NPI | 1982677803 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9111869) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: GA 2783) |
| 363AS0400X Physician Assistant, Surgical (Licence: AL PA756) | |
| 363AS0400X Physician Assistant, Surgical (Licence: NC 0010-01523) | |
| 363AS0400X Physician Assistant, Surgical (Licence: AR PA-1238) | |
| Enumeration Date | 2006-02-10 |
| Last Update Date | 2025-10-07 |