| NPI | 1467598185 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110840626) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: CA pa13000) |
| Enumeration Date | 2007-01-29 |
| Last Update Date | 2020-09-16 |