| NPI | 1629201280 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-01877) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NC 0010-01877) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2009-08-31 |
| Last Update Date | 2017-01-13 |