| NPI | 1831630664 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 11473934-1206) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WV 2038) |
| 363AS0400X Physician Assistant, Surgical (Licence: WY PT809) | |
| Enumeration Date | 2017-03-13 |
| Last Update Date | 2022-11-04 |