| NPI | 1801099015 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MA 2048) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 001666) |
| Enumeration Date | 2007-06-06 |
| Last Update Date | 2012-04-13 |