| NPI | 1578558409 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-00241) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NC 0010-00241) |
| 207P00000X Emergency Medicine (Licence: VA 0110001211) | |
| Enumeration Date | 2005-09-16 |
| Last Update Date | 2021-04-08 |