| NPI | 1417209610 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: SC 2274) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: GA 006576) |
| Enumeration Date | 2012-10-11 |
| Last Update Date | 2019-03-07 |