| NPI | 1811410038 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C06615) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MD C06615) |
| Enumeration Date | 2017-07-19 |
| Last Update Date | 2019-12-04 |