| NPI | 1568492650 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: AZ 3400) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 3400) |
| 363AM0700X Physician Assistant, Medical (Licence: AZ 3400) | |
| Enumeration Date | 2006-07-04 |
| Last Update Date | 2023-06-07 |