| NPI | 1689912362 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 108691) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: VA 0110004141) |
| Enumeration Date | 2013-01-30 |
| Last Update Date | 2021-10-05 |