| NPI | 1124413307 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: IA 084779) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MO 2015008634) |
| 363AS0400X Physician Assistant, Surgical (Licence: MO 2015008634) | |
| 363AS0400X Physician Assistant, Surgical (Licence: IA 084779) | |
| Enumeration Date | 2015-04-03 |
| Last Update Date | 2018-09-14 |