| NPI | 1679942981 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: 1127070) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical |
| Enumeration Date | 2015-09-16 |
| Last Update Date | 2022-01-19 |