| NPI | 1871546838 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OR PA172009) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9101478) |
| Enumeration Date | 2006-05-18 |
| Last Update Date | 2023-11-16 |