NPI | 1053691238 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: UT 5419926-1206) |
Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NC 0010-03061) |
363AS0400X Physician Assistant, Surgical (Licence: AZ 5153) | |
Enumeration Date | 2011-08-19 |
Last Update Date | 2018-01-25 |