| NPI | 1417209610 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110010461) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: GA 006576) |
| 363A00000X Physician Assistant (Licence: SC 2274) | |
| 363AS0400X Physician Assistant, Surgical (Licence: SC 2274) | |
| 363A00000X Physician Assistant (Licence: DE C5-0012183) | |
| Enumeration Date | 2012-10-11 |
| Last Update Date | 2026-05-12 |