| NPI | 1508958893 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CA 55450) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110004985) |
| 363A00000X Physician Assistant (Licence: ME PA1619) | |
| 363A00000X Physician Assistant (Licence: GA 004004) | |
| 363AS0400X Physician Assistant, Surgical (Licence: GA 004004) | |
| 363AS0400X Physician Assistant, Surgical (Licence: CT 003926) | |
| 363AS0400X Physician Assistant, Surgical (Licence: NM PA2020-0043) | |
| Enumeration Date | 2006-09-28 |
| Last Update Date | 2022-05-24 |