| NPI | 1073917209 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-07049) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9108348) |
| 363AM0700X Physician Assistant, Medical (Licence: NC 0010-07049) | |
| Enumeration Date | 2014-10-17 |
| Last Update Date | 2024-06-10 |