| NPI | 1245748045 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 2910) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-08907) |
| 207Q00000X Family Medicine (Licence: SC MPA.2910) | |
| 2086S0127X Surgery, Trauma Surgery (Licence: SC MPA.2910) | |
| Enumeration Date | 2018-01-15 |
| Last Update Date | 2026-08-04 |