| NPI | 1134822349 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: VA 0136000738) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: 205447) |
| Enumeration Date | 2023-03-24 |
| Last Update Date | 2023-03-24 |