| NPI | 1285147447 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9110760) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: FL 9110760) |
| Enumeration Date | 2017-11-09 |
| Last Update Date | 2025-07-28 |