| NPI | 1407845845 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: PA MA056681) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9103071) |
| Enumeration Date | 2005-10-18 |
| Last Update Date | 2014-05-07 |