| NPI | 1427539972 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: PA MA061786) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2018-08-23 |
| Last Update Date | 2021-12-15 |