| NPI | 1366803967 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: HI AMD-870) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WA PA60714731) |
| Enumeration Date | 2016-03-10 |
| Last Update Date | 2022-03-21 |