| NPI | 1699113753 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: WA PA60731358) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085004682) |
| Enumeration Date | 2013-06-11 |
| Last Update Date | 2017-05-11 |