| NPI | 1508820168 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 111902) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MO 111902) |
| Enumeration Date | 2006-04-12 |
| Last Update Date | 2022-08-16 |