| NPI | 1487742458 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: MA 804) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA804) |
| Enumeration Date | 2006-10-11 |
| Last Update Date | 2021-07-30 |