| NPI | 1578722641 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9105587) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: DE C5-0000572) |
| Enumeration Date | 2008-06-04 |
| Last Update Date | 2012-03-13 |