| NPI | 1275560849 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: LA PAA10589RX) |
| Enumeration Date | 2006-06-27 |
| Last Update Date | 2021-12-23 |