| NPI | 1174523393 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110002091) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA 1346) |
| 363AS0400X Physician Assistant, Surgical (Licence: MA 1346) | |
| 363AS0400X Physician Assistant, Surgical (Licence: VA 0110002091) | |
| Enumeration Date | 2005-07-29 |
| Last Update Date | 2007-07-08 |