| NPI | 1750495750 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MA PA2114) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9103790) |
| Enumeration Date | 2006-08-18 |
| Last Update Date | 2010-12-22 |