| NPI | 1477551620 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-10044) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA002789L) |
| 363AS0400X Physician Assistant, Surgical (Licence: PA MA002789L) | |
| Enumeration Date | 2005-07-12 |
| Last Update Date | 2020-04-21 |