| NPI | 1720361405 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CO PA0005635) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 1098276) |
| 363A00000X Physician Assistant (Licence: TX PA10199) | |
| Enumeration Date | 2011-09-20 |
| Last Update Date | 2024-02-02 |