NPI | 1134745664 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MT MED-PAC-LIC-115542) |
Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WA PA61100789) |
Enumeration Date | 2020-06-20 |
Last Update Date | 2023-02-21 |