| NPI | 1427624253 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: TN 4371) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY TC052) |
| Enumeration Date | 2021-06-02 |
| Last Update Date | 2023-08-10 |