| NPI | 1811916612 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AR PA-1113) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: IN 10000417A) |
| 363A00000X Physician Assistant (Licence: WI 21961-875) | |
| Enumeration Date | 2006-07-19 |
| Last Update Date | 2022-11-29 |