| NPI | 1639245293 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MO 102791) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MO 102791) |
| Enumeration Date | 2006-11-27 |
| Last Update Date | 2008-07-11 |