| NPI | 1669600888 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: OR PA156399) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: CA PA20373) |
| 363AS0400X Physician Assistant Surgical (Licence: WA PA60150184) | |
| Enumeration Date | 2009-06-25 |
| Last Update Date | 2024-04-01 |