| NPI | 1619223716 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: IL 238.000180) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: IL 238.000180) |
| Enumeration Date | 2012-07-26 |
| Last Update Date | 2015-10-15 |