| NPI | 1164805768 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CT 3370) |
| Additional Taxonomies | 2471C3402X Radiologic Technologist, Radiography (Licence: CT 6036) |
| Enumeration Date | 2015-07-01 |
| Last Update Date | 2023-06-30 |