| NPI | 1265788996 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207X00000X Orthopaedic Surgery (Licence: PA OT018304) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MD C0004777) |
| Enumeration Date | 2012-07-31 |
| Last Update Date | 2018-08-03 |