| NPI | 1770817348 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT 114160) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: AZ 5432) |
| 363AS0400X Physician Assistant, Surgical (Licence: WA PA60162605) | |
| Enumeration Date | 2009-09-29 |
| Last Update Date | 2023-12-29 |