| NPI | 1639483001 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: IA 082179) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: IA 082179) |
| Enumeration Date | 2010-07-28 |
| Last Update Date | 2025-01-13 |