| NPI | 1992741755 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA 2196) |
| Additional Taxonomies | 207P00000X Emergency Medicine (Licence: FL PA2196) |
| 363A00000X Physician Assistant (Licence: NM PA2016-0022) | |
| Enumeration Date | 2006-06-21 |
| Last Update Date | 2016-08-22 |