| NPI | 1932164605 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CA PA61588) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MI 5601003570) |
| 363AS0400X Physician Assistant, Surgical (Licence: ID PA602) | |
| Enumeration Date | 2006-04-18 |
| Last Update Date | 2023-02-22 |