| NPI | 1790030328 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA055634) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: PA MA055634) |
| Enumeration Date | 2012-07-19 |
| Last Update Date | 2022-02-09 |