| NPI | 1518539907 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 5489) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WI 5489-23) |
| Enumeration Date | 2021-07-14 |
| Last Update Date | 2021-11-22 |