| NPI | 1477211001 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: AZ 9506) |
| Additional Taxonomies | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: WI 22-397) |
| 363AM0700X Physician Assistant, Medical (Licence: FL TPPA284) | |
| 363AM0700X Physician Assistant, Medical (Licence: FL PACN33) | |
| 363AM0700X Physician Assistant, Medical (Licence: IN CV2200542) | |
| Enumeration Date | 2021-12-01 |
| Last Update Date | 2025-06-30 |