| NPI | 1043402373 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: AZ 9077) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KS T01462) |
| 363A00000X Physician Assistant (Licence: AZ 9077) | |
| 363AS0400X Physician Assistant Surgical (Licence: MO 2017012741) | |
| Enumeration Date | 2007-08-10 |
| Last Update Date | 2022-09-08 |