| NPI | 1093755886 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT MED-PAC-LIC-402) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MT 402) |
| 363AS0400X Physician Assistant, Surgical (Licence: MT 402) | |
| Enumeration Date | 2006-06-08 |
| Last Update Date | 2021-05-24 |