| NPI | 1508819749 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 101632) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: TN 1902) |
| Enumeration Date | 2006-05-18 |
| Last Update Date | 2022-04-12 |