| NPI | 1447931209 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 363A00000X Physician Assistant | 
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical | 
| 363AS0400X Physician Assistant, Surgical | |
| Enumeration Date | 2023-07-26 | 
| Last Update Date | 2025-06-16 |