| NPI | 1720379597 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: ID PA-1071) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: ID PA-1071) |
| Enumeration Date | 2011-04-27 |
| Last Update Date | 2013-12-16 |