| NPI | 1194711531 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-03143) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: OH 50.002274) |
| 363A00000X Physician Assistant (Licence: TX PA14640) | |
| Enumeration Date | 2005-09-21 |
| Last Update Date | 2026-07-03 |