| NPI | 1225003999 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: SD 0596) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: IA 001661) |
| 363AS0400X Physician Assistant, Surgical (Licence: NE 1340) | |
| Enumeration Date | 2006-02-17 |
| Last Update Date | 2015-11-12 |