| NPI | 1811541162 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: WA PA61110143) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: CO PA.0007227) |
| Enumeration Date | 2019-07-25 |
| Last Update Date | 2022-04-05 |