| NPI | 1417464777 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-07808) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363AS0400X Physician Assistant, Surgical (Licence: NC 0010-07808) | |
| Enumeration Date | 2018-01-08 |
| Last Update Date | 2023-02-23 |