| NPI | 1952402257 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: ID PA1007) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: UT 5124950-1206) |
| Enumeration Date | 2006-09-26 |
| Last Update Date | 2018-02-27 |