| NPI | 1073648465 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-00823) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical |
| Enumeration Date | 2007-02-23 |
| Last Update Date | 2022-01-14 |