| NPI | 1285988865 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 8516744-1206) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NV PA1386) |
| Enumeration Date | 2012-11-02 |
| Last Update Date | 2024-04-19 |