| NPI | 1023017977 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA002769L) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: PA MA002769L) |
| Enumeration Date | 2005-07-21 |
| Last Update Date | 2022-03-29 |