| NPI | 1336592708 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-07694) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-07694) |
| 363AS0400X Physician Assistant, Surgical (Licence: VA 0101-005458) | |
| Enumeration Date | 2016-07-20 |
| Last Update Date | 2022-01-04 |