| NPI | 1578521068 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MD C0000842) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MD C0000842) |
| Enumeration Date | 2006-05-03 |
| Last Update Date | 2020-01-24 |