| NPI | 1164866646 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: SC 4532) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9106938) |
| Enumeration Date | 2013-04-26 |
| Last Update Date | 2024-09-04 |