| NPI | 1114970209 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: TN 3495) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: TN 3495) |
| 363AM0700X Physician Assistant Medical (Licence: CT 001584) | |
| Enumeration Date | 2006-05-18 |
| Last Update Date | 2020-08-24 |