| NPI | 1003878125 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: AZ 6059) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA168858) |
| Enumeration Date | 2006-04-04 |
| Last Update Date | 2015-06-22 |