| NPI | 1982279675 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OR PA212094) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: CT 5319) |
| Enumeration Date | 2021-05-25 |
| Last Update Date | 2022-09-22 |