| NPI | 1003125055 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: LA PA200387) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: LA PA.200387) |
| Enumeration Date | 2010-09-24 |
| Last Update Date | 2020-07-28 |