| NPI | 1174925168 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: VA 0110006166) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MD C0005559) |
| Enumeration Date | 2014-09-22 |
| Last Update Date | 2025-08-06 |