| NPI | 1235195850 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 630) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: SC A630) |
| Enumeration Date | 2006-04-22 |
| Last Update Date | 2022-02-01 |