| NPI | 1720344872 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OR 173362) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NH 1529) |
| Enumeration Date | 2012-04-03 |
| Last Update Date | 2019-10-14 |