| NPI | 1932669876 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO 0006290) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: CA 56651) |
| Enumeration Date | 2019-03-25 |
| Last Update Date | 2022-01-21 |