| NPI | 1801886684 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 1059) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: SC 1059) |
| 363AS0400X Physician Assistant Surgical (Licence: SC 1059) | |
| Enumeration Date | 2005-10-24 |
| Last Update Date | 2007-07-09 |