| NPI | 1700122587 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OK 2194) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2012-12-23 |
| Last Update Date | 2020-10-08 |