| NPI | 1225120058 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: DE C50000136) | 
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: DE C50000136) | 
| Enumeration Date | 2006-09-29 | 
| Last Update Date | 2008-05-20 |