| NPI | 1518398502 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NC 001005216) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2013-12-02 |
| Last Update Date | 2018-12-10 |