| NPI | 1184623621 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: CO 3005) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 1058385) |
| Enumeration Date | 2005-07-18 |
| Last Update Date | 2024-02-13 |