| NPI | 1376098483 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MA PA5842) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA5842) |
| 363AM0700X Physician Assistant, Medical (Licence: MA PA5842) | |
| Enumeration Date | 2016-08-18 |
| Last Update Date | 2021-05-17 |