| NPI | 1093185191 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: MT MED-PAC-LIC-68103) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WY PT650) |
| Enumeration Date | 2015-10-01 |
| Last Update Date | 2021-12-14 |