| NPI | 1689761736 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CO 2030) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WY 489) |
| Enumeration Date | 2006-10-09 |
| Last Update Date | 2013-01-10 |