| NPI | 1952335465 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: NE 95) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: NE 95) |
| Enumeration Date | 2006-07-10 |
| Last Update Date | 2010-11-08 |