| NPI | 1629227640 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: VA 0110002872) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-09653) |
| Enumeration Date | 2008-09-15 |
| Last Update Date | 2022-09-14 |