NPI | 1104477116 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9112574) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9112574) |
Enumeration Date | 2019-09-23 |
Last Update Date | 2023-03-01 |