| NPI | 1619598620 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: TN 4112) |
| Enumeration Date | 2020-04-30 |
| Last Update Date | 2020-08-13 |