| NPI | 1255783114 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9112274) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: GA 7928) |
| 363A00000X Physician Assistant (Licence: FL PA9112274) | |
| Enumeration Date | 2016-07-05 |
| Last Update Date | 2025-10-29 |