| NPI | 1013317296 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1356) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: ID PA-1356) |
| Enumeration Date | 2014-08-25 |
| Last Update Date | 2025-07-09 |