| NPI | 1437552684 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA062727) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NC 0010) |
| 363AS0400X Physician Assistant, Surgical (Licence: MO 2019034485) | |
| Enumeration Date | 2014-10-02 |
| Last Update Date | 2022-01-02 |