NPI | 1104936533 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: PA MA051838) |
Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA015838) |
Enumeration Date | 2006-08-30 |
Last Update Date | 2020-04-17 |