| NPI | 1821097510 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: SC PA936) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 103940) |
| Enumeration Date | 2005-07-15 |
| Last Update Date | 2016-01-12 |