| NPI | 1205266053 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT MED-PAC-LIC-79860) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: ID PA1227) |
| Enumeration Date | 2013-11-14 |
| Last Update Date | 2023-05-31 |