| NPI | 1891797205 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA003157L) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: DE C5-0000626) |
| Enumeration Date | 2005-08-15 |
| Last Update Date | 2012-10-22 |