NPI | 1760931596 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: GA 10100606-1206) |
Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: UT 10100606-1206) |
Enumeration Date | 2016-09-21 |
Last Update Date | 2018-03-17 |