| NPI | 1669774469 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID 7361377) |
| Additional Taxonomies | 208600000X Surgery (Licence: PA MA054496) |
| 363A00000X Physician Assistant (Licence: PA MA054496) | |
| Enumeration Date | 2010-11-30 |
| Last Update Date | 2024-12-18 |