| NPI | 1962065516 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: IL 238.000655) |
| Additional Taxonomies | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: TX 19-180) |
| Enumeration Date | 2019-04-18 |
| Last Update Date | 2020-02-11 |