| NPI | 1366777583 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110003112) |
| 363AS0400X Physician Assistant Surgical (Licence: NV PA1611) | |
| Enumeration Date | 2009-10-06 |
| Last Update Date | 2021-10-06 |