| NPI | 1962832923 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: ID PA-1133) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: ID TLP-019) |
| Enumeration Date | 2013-11-12 |
| Last Update Date | 2018-03-29 |