| NPI | 1790651917 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: FL 20-190) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PR 2832-P.A.) |
| Enumeration Date | 2025-10-14 |
| Last Update Date | 2025-10-24 |