| NPI | 1700981206 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NC 0010-05849) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: GA 742) |
| 363A00000X Physician Assistant (Licence: NC 0010-05849) | |
| Enumeration Date | 2006-09-13 |
| Last Update Date | 2015-12-29 |