| NPI | 1023007077 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MT MED-PAC-LIC-445) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MT 445) |
| Enumeration Date | 2005-10-20 |
| Last Update Date | 2021-12-14 |