| NPI | 1649245309 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: VA 0110007007) |
| 363A00000X Physician Assistant (Licence: IN 10000928A) | |
| 363A00000X Physician Assistant (Licence: IL 85080096) | |
| Enumeration Date | 2006-02-17 |
| Last Update Date | 2020-08-06 |