| NPI | 1588664791 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 57092) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MT 398) |
| Enumeration Date | 2005-07-29 |
| Last Update Date | 2020-10-13 |