| NPI | 1912681867 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: NC 0010-13502) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-13502) |
| 363AS0400X Physician Assistant Surgical | |
| Enumeration Date | 2023-06-12 |
| Last Update Date | 2023-09-26 |