| NPI | 1326634312 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 9190) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WA PA60547938) |
| 363AS0400X Physician Assistant, Surgical (Licence: AZ 9190) | |
| Enumeration Date | 2020-12-15 |
| Last Update Date | 2022-08-08 |