| NPI | 1679091920 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 6865) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: AZ 6865) |
| Enumeration Date | 2017-09-07 |
| Last Update Date | 2022-07-29 |