| NPI | 1942544119 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: SC 2039) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: GA 004439) |
| 363A00000X Physician Assistant (Licence: GA 004439) | |
| 363AM0700X Physician Assistant, Medical (Licence: GA 004439) | |
| Enumeration Date | 2012-11-12 |
| Last Update Date | 2015-03-11 |