| NPI | 1720318348 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NC 0010-02147) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 0010 02147) |
| Enumeration Date | 2010-01-04 |
| Last Update Date | 2021-04-13 |