| NPI | 1891777645 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NE 1703) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: SD 0650) |
| 363AS0400X Physician Assistant, Surgical (Licence: IA 01626) | |
| Enumeration Date | 2005-11-17 |
| Last Update Date | 2023-12-13 |