| NPI | 1275956575 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-04768) |
| Additional Taxonomies | 207XX0005X Orthopaedic Surgery Sports Medicine (Licence: NC 0010-04768) |
| Enumeration Date | 2014-01-23 |
| Last Update Date | 2023-01-03 |