| NPI | 1366777153 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: OK 2510) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9105189) |
| Enumeration Date | 2009-10-12 |
| Last Update Date | 2015-05-15 |