| NPI | 1154307569 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: PA MA050819) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA002654) |
| 363AS0400X Physician Assistant Surgical (Licence: LA PA.200031) | |
| Enumeration Date | 2005-12-16 |
| Last Update Date | 2019-01-23 |