| NPI | 1023173002 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-06369) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NY 011678-1) |
| Enumeration Date | 2006-12-27 |
| Last Update Date | 2025-05-27 |