| NPI | 1295335487 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: SC Pending) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2020-10-28 |
| Last Update Date | 2025-01-24 |