| NPI | 1013217561 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110005258) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 014400) |
| 363AS0400X Physician Assistant, Surgical (Licence: CA 52182) | |
| Enumeration Date | 2010-11-01 |
| Last Update Date | 2021-09-24 |