| NPI | 1760636708 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: SC 2762) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363AS0400X Physician Assistant Surgical (Licence: SC 2762) | |
| Enumeration Date | 2008-11-04 |
| Last Update Date | 2021-07-02 |