| NPI | 1922763465 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 246ZS0410X Specialist/Technologist, Other Surgical Technologist |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: PR 1220) |
| 363AM0700X Physician Assistant Medical (Licence: PR 1202) | |
| Enumeration Date | 2021-10-31 |
| Last Update Date | 2022-09-05 |