| NPI | 1164789723 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MT MED-PAC-LIC-20141) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MT 20141) |
| Enumeration Date | 2012-04-19 |
| Last Update Date | 2022-02-24 |