| NPI | 1811997075 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: LA A10522) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: LA A10552) |
| Enumeration Date | 2005-07-28 |
| Last Update Date | 2024-02-05 |