| NPI | 1104854231 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA001387L) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: GA 002190) |
| Enumeration Date | 2006-06-29 |
| Last Update Date | 2007-07-08 |