| NPI | 1093705444 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: VA 0110001891) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NC 0101279) |
| Enumeration Date | 2005-10-26 |
| Last Update Date | 2007-12-17 |