| NPI | 1629525225 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: GA 8139) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 3548) |
| 363AS0400X Physician Assistant Surgical | |
| 363AS0400X Physician Assistant Surgical (Licence: SC 3548) | |
| Enumeration Date | 2016-09-01 |
| Last Update Date | 2020-11-13 |