| NPI | 1013912138 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2025051479) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: IN 10000261a) |
| 363A00000X Physician Assistant (Licence: IN 10000261a) | |
| 363AS0400X Physician Assistant, Surgical (Licence: KY PA415) | |
| Enumeration Date | 2005-06-15 |
| Last Update Date | 2026-04-14 |