| NPI | 1114344298 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2014006342) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MO 2014006342) |
| Enumeration Date | 2014-03-26 |
| Last Update Date | 2026-03-25 |