| NPI | 1679093124 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: DC PA031378) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2017-06-26 |
| Last Update Date | 2024-02-29 |