| NPI | 1811991789 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NE 961) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: NE 961) |
| Enumeration Date | 2005-06-09 |
| Last Update Date | 2021-02-09 |