| 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 |