| NPI | 1235895194 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: FL PA9115307) |
| Additional Taxonomies | 208200000X Plastic Surgery (Licence: FL PA9115307) |
| 363A00000X Physician Assistant (Licence: RI PA01644) | |
| Enumeration Date | 2021-11-15 |
| Last Update Date | 2025-07-29 |