| NPI | 1548579147 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MA PA8935) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: AZ 9765) |
| 363AS0400X Physician Assistant, Surgical (Licence: KY PA3383) | |
| Enumeration Date | 2010-09-29 |
| Last Update Date | 2024-11-05 |