| NPI | 1942679980 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: AL 1094) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AL 1812) |
| Enumeration Date | 2015-09-21 |
| Last Update Date | 2018-11-06 |