| NPI | 1689629644 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-01882) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 110001158) |
| 363AS0400X Physician Assistant, Surgical | |
| Enumeration Date | 2006-05-24 |
| Last Update Date | 2022-03-02 |