| NPI | 1780184184 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NC 0010-07909) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA061838) |
| Enumeration Date | 2018-02-13 |
| Last Update Date | 2021-04-29 |