| NPI | 1902017429 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 003320) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: AZ 3412) |
| Enumeration Date | 2007-05-25 |
| Last Update Date | 2019-06-19 |