| NPI | 1821145749 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA52173) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NC 100380) |
| 363A00000X Physician Assistant (Licence: KY PA1570) | |
| Enumeration Date | 2007-01-04 |
| Last Update Date | 2016-08-22 |