| NPI | 1679520050 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-00863) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NC 0010-00863) |
| 363AS0400X Physician Assistant, Surgical (Licence: MO 2006017175) | |
| Enumeration Date | 2006-05-30 |
| Last Update Date | 2022-06-14 |