| NPI | 1134745664 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: MT MED-PAC-LIC-115542) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: WA PA61100789) |
| Enumeration Date | 2020-06-20 |
| Last Update Date | 2023-02-21 |