| NPI | 1144220526 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: AZ 1593) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: AZ 1593) |
| Enumeration Date | 2005-07-28 |
| Last Update Date | 2008-02-05 |