| NPI | 1396865176 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C02466) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MD C0002466) |
| Enumeration Date | 2007-03-29 |
| Last Update Date | 2022-01-06 |