NPI | 1679186480 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 13362830-1206) |
Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WY PT972) |
Enumeration Date | 2020-08-31 |
Last Update Date | 2023-07-21 |