| NPI | 1710280144 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: ID PA-1016) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: AZ 4780) |
| Enumeration Date | 2010-12-07 |
| Last Update Date | 2012-12-06 |