| NPI | 1659644870 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CA 64402) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: OR PA164327) |
| Enumeration Date | 2012-02-18 |
| Last Update Date | 2024-07-11 |