| NPI | 1407453954 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: TN 4356) |
| Enumeration Date | 2020-10-07 |
| Last Update Date | 2021-04-01 |