| NPI | 1104890870 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 1014895) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: SC A777NS) |
| Enumeration Date | 2006-02-17 |
| Last Update Date | 2025-08-06 |