| NPI | 1245203132 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: SD 0568) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SD 0568) |
| Enumeration Date | 2006-02-10 |
| Last Update Date | 2023-03-07 |