| NPI | 1023972692 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: FL 21-558) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PR 2984) |
| 363AS0400X Physician Assistant, Surgical (Licence: PR 2984) | |
| Enumeration Date | 2025-12-09 |
| Last Update Date | 2025-12-09 |