| NPI | 1760757462 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MA PA4374) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA4374) |
| Enumeration Date | 2012-03-13 |
| Last Update Date | 2022-04-07 |