| NPI | 1881617603 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MD C00314) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: FL PA-0002219) |
| Enumeration Date | 2006-07-25 |
| Last Update Date | 2021-08-13 |