| NPI | 1275909418 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: UT 9852475-8906) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: CT 003467) |
| Enumeration Date | 2015-08-11 |
| Last Update Date | 2021-12-17 |