| NPI | 1740543081 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TN 4903) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WI 2969) |
| 363A00000X Physician Assistant (Licence: TN 4903) | |
| 363A00000X Physician Assistant (Licence: WI 2969) | |
| Enumeration Date | 2012-06-21 |
| Last Update Date | 2022-10-05 |