| NPI | 1174110753 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 106816) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: IA 106816) |
| Enumeration Date | 2020-12-29 |
| Last Update Date | 2021-04-05 |