| NPI | 1396141974 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 7425) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: NC 0010-13479) | |
| 363AS0400X Physician Assistant, Surgical (Licence: GA 007425) | |
| Enumeration Date | 2014-11-10 |
| Last Update Date | 2024-06-05 |