| NPI | 1184707457 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OK 407) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MI 5601002737) |
| Enumeration Date | 2006-10-23 |
| Last Update Date | 2019-08-26 |