| NPI | 1346794930 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MT MED-PAC-LIC-51936) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2016-08-11 |
| Last Update Date | 2021-12-14 |