| NPI | 1629042312 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: LA PA.200045.RX) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: LA PA.200045) |
| Enumeration Date | 2006-02-17 |
| Last Update Date | 2016-01-20 |