| NPI | 1164790234 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: VA 0110004010) |
| Enumeration Date | 2011-12-05 |
| Last Update Date | 2021-05-20 |