| NPI | 1164741419 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 002126) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: IA 002126) |
| Enumeration Date | 2010-05-26 |
| Last Update Date | 2012-12-18 |