| NPI | 1639787914 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PR 001457-P.A.) |
| Additional Taxonomies | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: WI 20-292) |
| Enumeration Date | 2020-07-22 |
| Last Update Date | 2022-11-06 |