| NPI | 1760435085 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: VA 0110003182) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110003182) |
| 363A00000X Physician Assistant (Licence: PA MA051878) | |
| Enumeration Date | 2006-05-18 |
| Last Update Date | 2022-10-21 |