| NPI | 1053128215 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical |
| Additional Taxonomies | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: FL 22-448) |
| 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: FL 24-448) | |
| Enumeration Date | 2024-12-11 |
| Last Update Date | 2025-04-01 |