| NPI | 1407732613 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PR 2633) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: TX 2633) |
| Enumeration Date | 2025-08-13 |
| Last Update Date | 2025-08-14 |