| NPI | 1093107997 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CA PA52384) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: VA 0110-004862) |
| 363AM0700X Physician Assistant, Medical (Licence: VA 0110-004862) | |
| Enumeration Date | 2015-03-02 |
| Last Update Date | 2017-04-12 |