| NPI | 1417047333 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: 646) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 646) |
| Enumeration Date | 2006-10-13 |
| Last Update Date | 2021-02-03 |