| NPI | 1417931312 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical |
| Additional Taxonomies | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: TX 3026) |
| 246ZS0410X Specialist/Technologist, Other, Surgical Technologist (Licence: TX SA00398) | |
| 246ZS0410X Specialist/Technologist, Other, Surgical Technologist (Licence: 871) | |
| Enumeration Date | 2005-12-04 |
| Last Update Date | 2014-02-23 |