| NPI | 1013965540 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: WV 2006) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: PA MA002064) |
| Enumeration Date | 2006-05-05 |
| Last Update Date | 2021-01-11 |