NPI | 1457914178 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 59560) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 7420) |
363AS0400X Physician Assistant, Surgical (Licence: FL PA9112389) | |
Enumeration Date | 2019-04-18 |
Last Update Date | 2022-06-23 |