| NPI | 1679828651 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 2996) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: MO 2024010639) |
| Enumeration Date | 2012-07-17 |
| Last Update Date | 2024-06-21 |