| NPI | 1477584068 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: PA MA053321) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 110002146) |
| Enumeration Date | 2006-07-05 |
| Last Update Date | 2010-05-21 |