NPI | 1821355454 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OR PA218898) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN PA2126) |
363A00000X Physician Assistant (Licence: CO PA.0006653) | |
Enumeration Date | 2012-04-20 |
Last Update Date | 2025-06-17 |