| NPI | 1003966367 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 1643) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MD C0003206) |
| Enumeration Date | 2007-01-11 |
| Last Update Date | 2015-06-25 |