| NPI | 1083614127 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: IN 99039830A) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MI 5601002612) |
| Enumeration Date | 2005-07-29 |
| Last Update Date | 2015-08-24 |