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 |