| NPI | 1659322105 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 5733) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: SC 792) |
| 363AS0400X Physician Assistant, Surgical (Licence: GA 5733) | |
| Enumeration Date | 2006-05-12 |
| Last Update Date | 2013-04-25 |