| NPI | 1063153492 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-15329) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: NC 0010-15329) |
| Enumeration Date | 2022-04-07 |
| Last Update Date | 2025-06-30 |