NPI | 1023369030 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OR PA170495) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 5236) |
Enumeration Date | 2012-10-01 |
Last Update Date | 2022-11-04 |