| NPI | 1104903871 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: VA 0110840218) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0000402) |
| Enumeration Date | 2006-11-01 |
| Last Update Date | 2021-08-16 |