| NPI | 1538444567 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: VA 0110004863) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA055287) |
| 363AS0400X Physician Assistant, Surgical (Licence: CA PA55543) | |
| 363AS0400X Physician Assistant, Surgical (Licence: FL PA9114549) | |
| Enumeration Date | 2011-10-21 |
| Last Update Date | 2023-12-12 |