| NPI | 1154620227 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-03466) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NC 0010-03466) |
| Enumeration Date | 2011-03-15 |
| Last Update Date | 2016-09-22 |