| NPI | 1124118377 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 00110003145) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: DE C5-0001388) |
| Enumeration Date | 2006-10-16 |
| Last Update Date | 2022-07-19 |