| NPI | 1417459900 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TX PA12730) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085-006531) |
| Enumeration Date | 2018-03-01 |
| Last Update Date | 2019-04-10 |