| NPI | 1629319298 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PR 002964) |
| Enumeration Date | 2013-03-07 |
| Last Update Date | 2025-11-15 |