| NPI | 1386295574 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9112549) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL 9112549) |
| Enumeration Date | 2019-09-27 |
| Last Update Date | 2020-01-10 |