| NPI | 1194389361 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical |
| Additional Taxonomies | 246ZC0007X Specialist/Technologist, Other Surgical Assistant |
| Enumeration Date | 2019-04-23 |
| Last Update Date | 2020-05-18 |