| NPI | 1669669628 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: IA 002044) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MN 1112) |
| 363A00000X Physician Assistant (Licence: WI 2199) | |
| Enumeration Date | 2007-10-03 |
| Last Update Date | 2024-01-26 |