| NPI | 1164822037 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: SD 0953) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 075330) |
| 363AS0400X Physician Assistant, Surgical (Licence: IA 075330) | |
| Enumeration Date | 2014-08-28 |
| Last Update Date | 2019-07-01 |