| NPI | 1588948087 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: ID PA-927) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: ID PA-927) |
| Enumeration Date | 2011-10-03 |
| Last Update Date | 2011-10-18 |