| NPI | 1073805941 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MA PA4529) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MD C0004457) |
| Enumeration Date | 2011-05-10 |
| Last Update Date | 2017-04-06 |