| NPI | 1508245911 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: WI 5774) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: DE C5-0012177) |
| 363AS0400X Physician Assistant, Surgical (Licence: FL PA9108643) | |
| Enumeration Date | 2015-05-19 |
| Last Update Date | 2025-09-23 |