| NPI | 1235652827 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: DE C5-0001274) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9110495) |
| Enumeration Date | 2017-07-25 |
| Last Update Date | 2022-06-16 |