| NPI | 1700063344 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: ID PA-1313) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: ID PA-1313) |
| 363A00000X Physician Assistant (Licence: ID PA-1313) | |
| Enumeration Date | 2008-01-25 |
| Last Update Date | 2016-10-20 |