| NPI | 1225295470 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical |
| Additional Taxonomies | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant |
| 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: CO 07-330) | |
| 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: CO SA.0001795) | |
| 363AS0400X Physician Assistant, Surgical (Licence: CO SA.0001795) | |
| Enumeration Date | 2008-05-16 |
| Last Update Date | 2022-09-19 |