| NPI | 1063718807 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: CA PA59559) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AR PA-875) |
| 363AS0400X Physician Assistant Surgical (Licence: GA 10891) | |
| 363AS0400X Physician Assistant Surgical (Licence: SC 530) | |
| Enumeration Date | 2011-01-26 |
| Last Update Date | 2024-09-19 |