| NPI | 1346550829 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2024004720) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: UT 2940731206) |
| Enumeration Date | 2010-10-18 |
| Last Update Date | 2024-07-11 |