| NPI | 1104257732 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: VA 0136000479) |
| Enumeration Date | 2013-12-08 |
| Last Update Date | 2023-01-03 |