| NPI | 1942305446 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-01142) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NC 0010-01142) |
| 363AS0400X Physician Assistant, Surgical (Licence: MA 1287) | |
| Enumeration Date | 2006-09-13 |
| Last Update Date | 2023-11-27 |