| NPI | 1275869711 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 1482) |
| Enumeration Date | 2009-10-18 |
| Last Update Date | 2019-04-11 |