| NPI | 1306396338 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110010482) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-11740) |
| 363AS0400X Physician Assistant, Surgical (Licence: WA PA60709306) | |
| Enumeration Date | 2016-10-14 |
| Last Update Date | 2024-12-10 |