| NPI | 1275725202 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: SC 2020) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: FL PA 9104209) |
| Enumeration Date | 2007-08-14 |
| Last Update Date | 2013-11-06 |