| NPI | 1164080321 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical |
| Additional Taxonomies | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: VA 5016) |
| Enumeration Date | 2019-06-03 |
| Last Update Date | 2023-06-05 |