| NPI | 1134832215 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical |
| 363AM0700X Physician Assistant, Medical | |
| Enumeration Date | 2023-01-03 |
| Last Update Date | 2025-10-08 |