| NPI | 1518940584 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NC 102360) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: SC 480) |
| Enumeration Date | 2005-11-23 |
| Last Update Date | 2017-06-01 |