| NPI | 1154421899 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA1531) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MA 1531) |
| Enumeration Date | 2006-09-23 |
| Last Update Date | 2022-01-25 |