| NPI | 1487922159 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: AZ 4922) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 4922) |
| 363AM0700X Physician Assistant, Medical (Licence: AZ 4922) | |
| Enumeration Date | 2011-12-08 |
| Last Update Date | 2014-01-17 |