| NPI | 1801142146 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1153) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WA PA60306120) |
| Enumeration Date | 2012-07-24 |
| Last Update Date | 2023-03-07 |