| NPI | 1235709890 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 4633) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: TN 4633) |
| Enumeration Date | 2021-06-28 |
| Last Update Date | 2022-06-02 |