| NPI | 1104201201 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: VA 0110-007005) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MD C0006368) |
| Enumeration Date | 2015-07-30 |
| Last Update Date | 2024-11-04 |