| NPI | 1518006873 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA4497) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: GA 4992) |
| Enumeration Date | 2007-02-05 |
| Last Update Date | 2013-01-08 |