| NPI | 1194787440 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: PA MA003501L) |
| Enumeration Date | 2006-04-03 |
| Last Update Date | 2020-02-10 |