| NPI | 1336465426 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA 4807) |
| 363AS0400X Physician Assistant, Surgical (Licence: PA MA054338) | |
| Enumeration Date | 2010-04-14 |
| Last Update Date | 2018-04-19 |