| NPI | 1407067507 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: VA 0110004200) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 1499) |
| 363AM0700X Physician Assistant, Medical (Licence: TN 1499) | |
| 363AS0400X Physician Assistant, Surgical (Licence: TN 1449) | |
| Enumeration Date | 2007-05-24 |
| Last Update Date | 2022-08-23 |