| NPI | 1760458210 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OK 2055) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MO 2005002890) |
| Enumeration Date | 2006-02-24 |
| Last Update Date | 2018-01-05 |