| NPI | 1629527643 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: GA 8771) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA9109886) |
| Enumeration Date | 2016-10-03 |
| Last Update Date | 2018-08-08 |