NPI | 1407732613 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PR 2633) |
Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: TX 2633) |
Enumeration Date | 2025-08-13 |
Last Update Date | 2025-08-14 |