NPI | 1003153800 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: AZ 5331) |
Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: AZ 5331) |
Enumeration Date | 2013-01-14 |
Last Update Date | 2013-01-14 |