| NPI | 1356123863 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: ID 6571244) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2023-10-18 |
| Last Update Date | 2025-02-07 |