| NPI | 1740366111 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OK 4618) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: CO 2567) |
| Enumeration Date | 2006-10-28 |
| Last Update Date | 2021-09-22 |