| NPI | 1053331587 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9110640) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA00885) |
| Enumeration Date | 2006-07-20 |
| Last Update Date | 2022-07-21 |