| NPI | 1053795997 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: DE C5-0001378) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: VA 0110-005018) |
| Enumeration Date | 2015-07-09 |
| Last Update Date | 2022-10-05 |