| NPI | 1164568135 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: GA 3198) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 003198) |
| 363AS0400X Physician Assistant, Surgical (Licence: AL PA.657) | |
| Enumeration Date | 2007-01-29 |
| Last Update Date | 2025-04-03 |