| NPI | 1508496845 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: SC 4084) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: ME PA2032) |
| 363AS0400X Physician Assistant Surgical (Licence: OH 50.006024) | |
| Enumeration Date | 2020-01-24 |
| Last Update Date | 2021-09-27 |