| NPI | 1033291869 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: 1799) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WI 1799) |
| Enumeration Date | 2006-10-20 |
| Last Update Date | 2021-02-16 |