| NPI | 1861423170 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: KY PA1733) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 50.002649RX) |
| 363AS0400X Physician Assistant Surgical (Licence: IL 085001586) | |
| Enumeration Date | 2006-07-05 |
| Last Update Date | 2017-02-01 |