| NPI | 1952631087 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 008891) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: FL PA 9105987) |
| Enumeration Date | 2010-01-13 |
| Last Update Date | 2018-10-11 |