| NPI | 1184377731 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: SC 5354) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 5354) |
| 363A00000X Physician Assistant (Licence: NC 0010-11771) | |
| Enumeration Date | 2022-02-02 |
| Last Update Date | 2026-05-21 |