| NPI | 1306884671 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MD C01921) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: VA 0110840565) |
| 363A00000X Physician Assistant (Licence: MD C01921) | |
| Enumeration Date | 2006-06-02 |
| Last Update Date | 2021-06-03 |