| NPI | 1124001409 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 367H00000X Anesthesiologist Assistant (Licence: DC AA000026) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: AZ 1981) |
| Enumeration Date | 2005-11-21 |
| Last Update Date | 2010-09-15 |