| NPI | 1710291612 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 1720) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: SC 1720) |
| Enumeration Date | 2010-08-03 |
| Last Update Date | 2021-06-30 |