| NPI | 1164977005 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110-005499) |
| Enumeration Date | 2016-08-21 |
| Last Update Date | 2019-08-05 |