| NPI | 1073287785 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 7234) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: UT 12460798-1206) |
| Enumeration Date | 2021-08-05 |
| Last Update Date | 2023-04-05 |