| NPI | 1447859400 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 3818) |
| Additional Taxonomies | 207XX0005X Orthopaedic Surgery, Sports Medicine (Licence: TX 33436646) |
| Enumeration Date | 2020-10-21 |
| Last Update Date | 2021-06-08 |