| NPI | 1255768412 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OR PA170172) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363AS0400X Physician Assistant, Surgical (Licence: CO PA4766) | |
| Enumeration Date | 2013-10-02 |
| Last Update Date | 2023-08-30 |