| NPI | 1134753908 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 7790) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: AZ 7790) |
| Enumeration Date | 2020-03-02 |
| Last Update Date | 2022-07-29 |