| NPI | 1053714402 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 4759) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: CT 4773) |
| Enumeration Date | 2014-09-30 |
| Last Update Date | 2023-08-21 |