| NPI | 1275586331 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-07369) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA 4180) |
| 363AS0400X Physician Assistant, Surgical (Licence: MA PA4180) | |
| 363AS0400X Physician Assistant, Surgical (Licence: NC 0010-07369) | |
| Enumeration Date | 2006-05-18 |
| Last Update Date | 2021-05-26 |