| NPI | 1851676118 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: WA PA60373777) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 25MP00270600) |
| Enumeration Date | 2011-10-19 |
| Last Update Date | 2013-12-06 |