| NPI | 1881654218 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MO 2024007425) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MT 104416) |
| 363A00000X Physician Assistant (Licence: AR PA-870) | |
| 363AS0400X Physician Assistant, Surgical (Licence: NM 98-PA09) | |
| Enumeration Date | 2006-03-28 |
| Last Update Date | 2024-04-23 |