| NPI | 1144698978 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SD 1037) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 6165) |
| 363AS0400X Physician Assistant Surgical (Licence: AZ 6165) | |
| Enumeration Date | 2015-09-10 |
| Last Update Date | 2019-09-12 |