| NPI | 1316483332 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: FL 15-189) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PR 0592-P.A.) |
| 363AS0400X Physician Assistant, Surgical (Licence: PR 0592-P.A.) | |
| Enumeration Date | 2017-01-13 |
| Last Update Date | 2025-12-08 |