| NPI | 1376799304 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WY 438) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: WY 438) |
| Enumeration Date | 2008-08-11 |
| Last Update Date | 2017-03-21 |