| NPI | 1104207075 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CO 13-284) |
| Additional Taxonomies | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: CO 13-284) |
| Enumeration Date | 2015-06-16 |
| Last Update Date | 2015-12-04 |