| NPI | 1356852446 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-07748) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: IL 085-006277) |
| Enumeration Date | 2017-10-17 |
| Last Update Date | 2021-08-20 |