| NPI | 1619959756 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: GA 000870) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: GA 0044308) |
| Enumeration Date | 2005-11-15 |
| Last Update Date | 2009-11-24 |