| NPI | 1790193829 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: SC 2372) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110004667) |
| Enumeration Date | 2014-08-01 |
| Last Update Date | 2015-10-23 |