| NPI | 1699884205 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: MD C02860) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical |
| 363AS0400X Physician Assistant Surgical (Licence: MD C02860) | |
| Enumeration Date | 2006-08-29 |
| Last Update Date | 2024-04-01 |