| NPI | 1295903342 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-06049) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9104485) |
| Enumeration Date | 2008-02-12 |
| Last Update Date | 2021-04-21 |