| NPI | 1053427765 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 821) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WI 821) |
| Enumeration Date | 2006-08-23 |
| Last Update Date | 2012-03-30 |