| NPI | 1558517292 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO 4192) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: IL 085.003259) |
| Enumeration Date | 2008-08-13 |
| Last Update Date | 2022-02-10 |