| NPI | 1417229816 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: VA 0110003793) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: VA 0110003793) |
| Enumeration Date | 2012-01-31 |
| Last Update Date | 2013-06-06 |