| NPI | 1093141913 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: NC 0010-06605) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2013-09-24 |
| Last Update Date | 2018-11-30 |