| NPI | 1811296882 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MD C0007384) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: VA 0110003484) |
| Enumeration Date | 2011-03-16 |
| Last Update Date | 2019-12-13 |