| NPI | 1124076757 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: AZ 1320) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2010041704) |
| 363AM0700X Physician Assistant, Medical (Licence: AZ 1320) | |
| Enumeration Date | 2006-05-05 |
| Last Update Date | 2021-01-12 |