| NPI | 1740263144 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA052660) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: DE C5-0000494) |
| Enumeration Date | 2005-11-21 |
| Last Update Date | 2015-10-23 |