| NPI | 1114186970 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C0003671) | 
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MD C0003671) | 
| Enumeration Date | 2008-06-06 | 
| Last Update Date | 2008-06-06 |