| NPI | 1457597221 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: GA 005532) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: GA 005532) |
| Enumeration Date | 2008-12-29 |
| Last Update Date | 2020-12-08 |