| NPI | 1104135706 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: NC 0010-09188) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NC P12724) |
| Enumeration Date | 2010-09-29 |
| Last Update Date | 2019-06-26 |