| NPI | 1861808727 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TX PA10578) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NY 017694) |
| Enumeration Date | 2014-07-10 |
| Last Update Date | 2017-06-09 |