| NPI | 1568767093 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: AK 120081) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 6036) |
| Enumeration Date | 2011-01-13 |
| Last Update Date | 2017-04-20 |