| NPI | 1477687382 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110840862) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: VA 0110840862) |
| Enumeration Date | 2007-03-15 |
| Last Update Date | 2022-02-01 |