| NPI | 1376967653 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CA 51418) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: CO PA.0008275) |
| 363AS0400X Physician Assistant, Surgical (Licence: TX PA18062) | |
| Enumeration Date | 2014-02-07 |
| Last Update Date | 2025-04-24 |