| NPI | 1417912007 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NC 0010-00385 PA-C) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-00385) |
| Enumeration Date | 2006-04-18 |
| Last Update Date | 2021-05-27 |