| NPI | 1114136454 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: PA MA053816) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MT MED-PAC-LIC-101201) |
| 363A00000X Physician Assistant (Licence: MT MED-PAC-LIC-101201) | |
| Enumeration Date | 2007-05-22 |
| Last Update Date | 2026-07-22 |