| NPI | 1659861557 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: 4894) |
| Additional Taxonomies | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: VA 4894) |
| Enumeration Date | 2018-05-16 |
| Last Update Date | 2020-11-16 |