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 |