NPI | 1669725644 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CA 61454) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 61454) |
363A00000X Physician Assistant | |
363A00000X Physician Assistant (Licence: VA 0110005055) | |
Enumeration Date | 2012-10-16 |
Last Update Date | 2025-08-14 |