| NPI | 1336458587 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA OA002565) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: PA MA054682) |
| Enumeration Date | 2010-10-05 |
| Last Update Date | 2022-06-08 |