| NPI | 1821604067 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: PA MA065440) |
| Additional Taxonomies | 208200000X Plastic Surgery (Licence: MA PA8441) |
| Enumeration Date | 2020-09-22 |
| Last Update Date | 2024-04-24 |