| NPI | 1265299754 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA100561) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: MA PA100561) |
| Enumeration Date | 2024-03-01 |
| Last Update Date | 2024-08-07 |