| NPI | 1104801315 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: UT 6224324-1206) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: OR PA00880) |
| Enumeration Date | 2005-12-09 |
| Last Update Date | 2022-04-08 |