| NPI | 1396094108 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WY 554) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical |
| Enumeration Date | 2012-09-07 |
| Last Update Date | 2017-01-10 |