| NPI | 1225275761 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-01648) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NC 0010-01648) |
| Enumeration Date | 2009-01-20 |
| Last Update Date | 2021-03-31 |