| NPI | 1033383104 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: PA MA053351) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 3285) |
| Enumeration Date | 2008-04-18 |
| Last Update Date | 2025-09-05 |