| NPI | 1477187649 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 105262) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: IA 105262) |
| 363A00000X Physician Assistant (Licence: WI 4989-23) | |
| 363AS0400X Physician Assistant, Surgical (Licence: WI 4989-23) | |
| Enumeration Date | 2020-02-26 |
| Last Update Date | 2021-01-11 |