| NPI | 1659596922 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: 757 - OPA-C CERT #) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: CERT 757) |
| Enumeration Date | 2007-04-13 |
| Last Update Date | 2008-10-08 |