| NPI | 1750734984 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 9789) |
| 363A00000X Physician Assistant (Licence: TX PA12046) | |
| Enumeration Date | 2016-07-23 |
| Last Update Date | 2021-09-16 |