| NPI | 1700183985 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TX CSA-08108) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: DC SA-0130) |
| Enumeration Date | 2011-02-23 |
| Last Update Date | 2016-04-05 |