| NPI | 1326390121 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OR PA195088) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: DE C50000833) |
| 363AS0400X Physician Assistant, Surgical (Licence: FL PA9108012) | |
| Enumeration Date | 2012-10-04 |
| Last Update Date | 2024-01-08 |