| NPI | 1013999119 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: GA 1268) |
| Additional Taxonomies | 246ZS0410X Specialist/Technologist, Other, Surgical Technologist (Licence: VA 1268) |
| 363AS0400X Physician Assistant, Surgical | |
| Enumeration Date | 2005-11-16 |
| Last Update Date | 2022-06-06 |