| NPI | 1194726307 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MO 2009014905) |
| Additional Taxonomies | 208600000X Surgery (Licence: KS 15-00245) |
| Enumeration Date | 2005-08-10 |
| Last Update Date | 2019-06-19 |