| NPI | 1225368483 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-03472) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: VA 0110003211) |
| 363AS0400X Physician Assistant, Surgical (Licence: NC 0010-03472) | |
| Enumeration Date | 2010-01-11 |
| Last Update Date | 2022-09-01 |