| NPI | 1104491265 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA064625) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 12387748-1206) |
| 363AS0400X Physician Assistant, Surgical (Licence: UT 12387748-1206) | |
| Enumeration Date | 2021-05-21 |
| Last Update Date | 2024-05-08 |