| NPI | 1205325438 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA8951) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110006208) |
| 363AS0400X Physician Assistant Surgical | |
| Enumeration Date | 2018-05-03 |
| Last Update Date | 2022-09-20 |