| NPI | 1053745190 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NC 0010-11068) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 1974) |
| Enumeration Date | 2013-08-26 |
| Last Update Date | 2021-11-30 |