NPI | 1104801315 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: UT 6224324-1206) |
Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: OR PA00880) |
Enumeration Date | 2005-12-09 |
Last Update Date | 2022-04-08 |