| NPI | 1346121118 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208000000X Pediatrics (Licence: FL PA9120676) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9120676) |
| 363AS0400X Physician Assistant, Surgical (Licence: FL PA9120676) | |
| Enumeration Date | 2025-09-09 |
| Last Update Date | 2025-09-09 |