| NPI | 1730856303 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 9623) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: AZ 9623) |
| Enumeration Date | 2021-08-23 |
| Last Update Date | 2023-04-19 |