| NPI | 1306813563 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WV 835) |
| Additional Taxonomies | 208800000X Urology (Licence: WV 835) |
| 208600000X Surgery (Licence: WV 835) | |
| Enumeration Date | 2006-03-07 |
| Last Update Date | 2025-09-22 |