| NPI | 1356993497 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 10595) |
| Additional Taxonomies | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: FL 16-280) |
| Enumeration Date | 2019-07-09 |
| Last Update Date | 2024-12-02 |