| NPI | 1114026077 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MD C0002683) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MD C0002683) |
| Enumeration Date | 2006-09-21 |
| Last Update Date | 2016-12-28 |