| NPI | 1710319553 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MD C0005138) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MD C0005138) |
| 363A00000X Physician Assistant (Licence: MD C0005138) | |
| Enumeration Date | 2013-08-03 |
| Last Update Date | 2021-06-03 |