| NPI | 1265061808 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-15330) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CT 005065) |
| 363AS0400X Physician Assistant, Surgical | |
| Enumeration Date | 2020-04-06 |
| Last Update Date | 2025-08-05 |