| NPI | 1265083976 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9112678) | 
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 033537) | 
| Enumeration Date | 2019-09-24 | 
| Last Update Date | 2025-06-19 |