| NPI | 1336890615 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: MA PA8521) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA PA8521) |
| Enumeration Date | 2022-01-18 |
| Last Update Date | 2025-02-21 |