| NPI | 1205982907 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: VA 0110002504) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: DC PA30263) |
| Enumeration Date | 2007-01-26 |
| Last Update Date | 2019-01-02 |