| NPI | 1124755129 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: NC 001012478) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 1191636) |
| Enumeration Date | 2022-08-01 |
| Last Update Date | 2022-08-01 |