| NPI | 1073444022 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: SC 6496) |
| Enumeration Date | 2026-05-28 |
| Last Update Date | 2026-09-03 |