| NPI | 1265979280 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: NC 0010-07720) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical |
| Enumeration Date | 2017-01-28 |
| Last Update Date | 2018-02-26 |