| NPI | 1972520740 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: SC 2387) |
| Additional Taxonomies | 2085R0202X Radiology, Diagnostic Radiology (Licence: MI 5601004531) |
| Enumeration Date | 2006-07-16 |
| Last Update Date | 2020-11-06 |