| NPI | 1508336637 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical |
| Additional Taxonomies | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: 185997) |
| 246ZS0410X Specialist/Technologist, Other, Surgical Technologist (Licence: 111590) | |
| Enumeration Date | 2018-12-02 |
| Last Update Date | 2019-02-11 |