| NPI | 1801877022 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MS PA00164) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: AL PA-183) |
| Enumeration Date | 2005-11-07 |
| Last Update Date | 2017-03-22 |