| NPI | 1396800918 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: GA 174820) |
| Additional Taxonomies | 246ZS0410X Specialist/Technologist, Other, Surgical Technologist (Licence: GA 95942) |
| 363AS0400X Physician Assistant, Surgical (Licence: CO 1253) | |
| Enumeration Date | 2006-12-26 |
| Last Update Date | 2018-03-17 |