| NPI | 1396254132 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-07585) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN 4045) |
| 363AS0400X Physician Assistant, Surgical (Licence: TN 4045) | |
| Enumeration Date | 2017-09-25 |
| Last Update Date | 2025-11-18 |