| NPI | 1306209473 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: VA 0110005310) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110-005310) |
| Enumeration Date | 2016-04-05 |
| Last Update Date | 2021-06-01 |