| NPI | 1700880333 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: WI 1178) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: MN 9485) |
| Enumeration Date | 2005-06-10 |
| Last Update Date | 2015-07-30 |