| NPI | 1124061627 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 10696) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 5004689RX) |
| 363AS0400X Physician Assistant Surgical (Licence: MA PA6922) | |
| Enumeration Date | 2006-06-13 |
| Last Update Date | 2023-01-10 |