| NPI | 1083770192 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: ID M7482) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WA 00034506) |
| Enumeration Date | 2006-12-31 |
| Last Update Date | 2020-11-12 |