| NPI | 1508496845 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 12810) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: OH 50.006024) |
| 363AS0400X Physician Assistant, Surgical (Licence: ME PA2032) | |
| 363AS0400X Physician Assistant, Surgical (Licence: SC 4084) | |
| Enumeration Date | 2020-01-24 |
| Last Update Date | 2025-01-13 |