| NPI | 1174599906 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-06284) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: CT 001665) |
| Enumeration Date | 2006-02-23 |
| Last Update Date | 2016-07-06 |