| NPI | 1336759513 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 10926) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 58811) |
| 363AS0400X Physician Assistant, Surgical (Licence: CA 58811) | |
| Enumeration Date | 2020-08-03 |
| Last Update Date | 2022-11-28 |