| NPI | 1134458524 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 174400000X Specialist (Licence: IL 238.000243) |
| Additional Taxonomies | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: IL 238000243) |
| 363AS0400X Physician Assistant, Surgical (Licence: IL 238.000243) | |
| Enumeration Date | 2009-12-14 |
| Last Update Date | 2020-03-11 |