| NPI | 1578961967 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TN 2700) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TN 2700) |
| Enumeration Date | 2014-12-17 |
| Last Update Date | 2015-05-26 |