| NPI | 1073518783 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: WI 428) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: IA 2168) |
| Enumeration Date | 2005-06-17 |
| Last Update Date | 2015-05-15 |