NPI | 1417459900 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TX PA12730) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085-006531) |
Enumeration Date | 2018-03-01 |
Last Update Date | 2019-04-10 |