| NPI | 1023369030 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OR PA170495) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 5236) |
| Enumeration Date | 2012-10-01 |
| Last Update Date | 2022-11-04 |