| NPI | 1548255797 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TX 1049845) |
| Enumeration Date | 2005-09-14 |
| Last Update Date | 2018-08-09 |