| NPI | 1972708543 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA052992) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: PA MA 052992) |
| Enumeration Date | 2007-06-15 |
| Last Update Date | 2022-06-08 |