| NPI | 1790018224 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA OA002401) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: PA MA054092) |
| Enumeration Date | 2009-09-16 |
| Last Update Date | 2012-02-01 |