| NPI | 1164194593 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MT MED-PAC-LIC-131239) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WY PT956) |
| Enumeration Date | 2021-10-04 |
| Last Update Date | 2025-12-09 |