| NPI | 1003594482 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MA PA100066) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA100066) |
| 363AM0700X Physician Assistant, Medical (Licence: MA PA100066) | |
| Enumeration Date | 2023-07-06 |
| Last Update Date | 2025-03-03 |