| NPI | 1740585280 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: VA 0110004244) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: NC 0010-02676) |
| 363AS0400X Physician Assistant Surgical (Licence: NC 0010-02676) | |
| Enumeration Date | 2011-01-13 |
| Last Update Date | 2013-08-12 |