| NPI | 1407839079 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 104182) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: NC 0001-04182) |
| Enumeration Date | 2005-11-28 |
| Last Update Date | 2016-11-21 |