| NPI | 1457354862 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 103358) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NC 103358) |
| Enumeration Date | 2005-05-31 |
| Last Update Date | 2019-06-05 |