| NPI | 1053691238 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: UT 5419926-1206) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NC 0010-03061) |
| 363AS0400X Physician Assistant, Surgical (Licence: AZ 5153) | |
| Enumeration Date | 2011-08-19 |
| Last Update Date | 2018-01-25 |