| NPI | 1558670307 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: PA MA054278) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA054278) |
| Enumeration Date | 2010-09-28 |
| Last Update Date | 2022-07-29 |