| NPI | 1962738146 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NC 1000406) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 1000406) |
| Enumeration Date | 2009-10-23 |
| Last Update Date | 2021-02-23 |