NPI | 1508130378 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: VA 0110-008889) |
Additional Taxonomies | 363A00000X Physician Assistant |
363AS0400X Physician Assistant, Surgical (Licence: CA 52298) | |
Enumeration Date | 2012-02-26 |
Last Update Date | 2022-12-14 |