| NPI | 1174924922 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: TN 4597) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: VA 0110004732) |
| 363AS0400X Physician Assistant Surgical (Licence: VA 0110004732) | |
| 363AS0400X Physician Assistant Surgical (Licence: TN 4597) | |
| Enumeration Date | 2014-09-11 |
| Last Update Date | 2021-09-22 |