| NPI | 1891232807 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: AZ 6662) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 3547) |
| 363AS0400X Physician Assistant Surgical (Licence: SC 3547) | |
| Enumeration Date | 2017-01-27 |
| Last Update Date | 2023-03-23 |