| NPI | 1609851005 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: NE 966) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: NE 1213) |
| Enumeration Date | 2005-12-08 |
| Last Update Date | 2012-02-14 |