| NPI | 1558399923 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MO 2013029322) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WA PA10002052) |
| 363AS0400X Physician Assistant, Surgical (Licence: NE 1999) | |
| Enumeration Date | 2006-06-28 |
| Last Update Date | 2021-03-17 |