| NPI | 1356543565 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: DE C50001153) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: TX PA04942) |
| 363AS0400X Physician Assistant, Surgical (Licence: CA PA16989) | |
| Enumeration Date | 2007-06-01 |
| Last Update Date | 2021-07-01 |