| NPI | 1558870113 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical |
| Additional Taxonomies | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: GA 178053) |
| Enumeration Date | 2017-09-27 |
| Last Update Date | 2022-01-25 |