| NPI | 1790870673 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C03858) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA052876) |
| 363AS0400X Physician Assistant, Surgical (Licence: DE C5-0000557) | |
| Enumeration Date | 2006-10-04 |
| Last Update Date | 2011-07-27 |