| NPI | 1700836863 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: VA 0110840560) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: VA 0110840560) |
| Enumeration Date | 2006-05-11 |
| Last Update Date | 2012-04-12 |