| NPI | 1891065728 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: GA 6333) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 6333) |
| 363AS0400X Physician Assistant Surgical (Licence: GA 6333) | |
| Enumeration Date | 2012-01-10 |
| Last Update Date | 2022-10-04 |