| NPI | 1366779357 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA054123) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: PA MA054123) |
| 363AM0700X Physician Assistant, Medical (Licence: PA MA054123) | |
| 363A00000X Physician Assistant (Licence: SC 3472) | |
| Enumeration Date | 2009-11-11 |
| Last Update Date | 2026-04-08 |