| NPI | 1740659762 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA057958) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: PA MA057958) |
| 363AS0400X Physician Assistant, Surgical (Licence: PA OA003665) | |
| Enumeration Date | 2015-09-21 |
| Last Update Date | 2020-08-31 |