| NPI | 1760604011 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical |
| Additional Taxonomies | 246ZS0410X Specialist/Technologist, Other, Surgical Technologist (Licence: AZ F01379) |
| Enumeration Date | 2007-05-03 |
| Last Update Date | 2018-11-17 |