| NPI | 1720049836 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MD C0003108) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C03108) |
| Enumeration Date | 2006-03-29 |
| Last Update Date | 2013-08-30 |