NPI | 1700136587 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9120236) |
Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: CT 002845) |
Enumeration Date | 2012-09-19 |
Last Update Date | 2025-06-26 |