| NPI | 1083075154 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA058279) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: PA MA058279) |
| 363AM0700X Physician Assistant, Medical (Licence: PA MA058279) | |
| 363AS0400X Physician Assistant, Surgical (Licence: PA OA003822) | |
| 363AM0700X Physician Assistant, Medical (Licence: PA OA003822) | |
| Enumeration Date | 2016-03-16 |
| Last Update Date | 2018-01-17 |