| NPI | 1164400479 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NM 2001-PA35) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NM 2001-PA35) |
| Enumeration Date | 2006-01-06 |
| Last Update Date | 2013-07-16 |