| NPI | 1669025649 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: TX SA00906) |
| Additional Taxonomies | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: WI 17-438) |
| Enumeration Date | 2019-07-19 |
| Last Update Date | 2023-02-13 |