| NPI | 1760784797 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: WA PA60285528) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9105721) |
| Enumeration Date | 2010-11-24 |
| Last Update Date | 2012-07-11 |