| NPI | 1164689402 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NC 0010-03759) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: SC 1243) |
| 363AM0700X Physician Assistant, Medical (Licence: SC 1243) | |
| Enumeration Date | 2008-05-22 |
| Last Update Date | 2013-01-11 |