| NPI | 1508101643 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C05396) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-03661) |
| 363AS0400X Physician Assistant, Surgical (Licence: NC 0010-03661) | |
| Enumeration Date | 2012-11-29 |
| Last Update Date | 2022-02-24 |