| NPI | 1033724307 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: MT MED-PAC-LIC-90413) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2020-09-13 |
| Last Update Date | 2021-01-04 |