| NPI | 1356355986 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 369118-1206) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: UT 369118-8906) |
| Enumeration Date | 2006-07-28 |
| Last Update Date | 2011-01-14 |