| NPI | 1215202510 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: MO 2012008459) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: MO 2012008459) |
| Enumeration Date | 2012-03-20 |
| Last Update Date | 2012-03-20 |