| NPI | 1861546715 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: DE C5-0000450) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD c03475) |
| Enumeration Date | 2007-01-22 |
| Last Update Date | 2009-10-02 |