| NPI | 1629074505 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: NH 1188) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: CO 585) |
| Enumeration Date | 2005-06-24 |
| Last Update Date | 2020-01-08 |