| NPI | 1063674380 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: VA 0110003260) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NH 0284P) |
| Enumeration Date | 2008-06-27 |
| Last Update Date | 2010-07-19 |