| NPI | 1124162581 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NC 104159) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 104159) |
| Enumeration Date | 2007-02-19 |
| Last Update Date | 2024-01-08 |