| NPI | 1275081119 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC PA3648) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-12373) |
| 363AS0400X Physician Assistant, Surgical (Licence: NY 020141) | |
| Enumeration Date | 2016-09-20 |
| Last Update Date | 2023-04-19 |