| NPI | 1558797365 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: WA PA61208141) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9107470) |
| 363AS0400X Physician Assistant, Surgical (Licence: OR PA182241) | |
| Enumeration Date | 2013-09-25 |
| Last Update Date | 2021-10-28 |