NPI | 1609365444 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CA 56188) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 56188) |
363AM0700X Physician Assistant, Medical (Licence: CA 56188) | |
Enumeration Date | 2018-05-08 |
Last Update Date | 2020-01-14 |