| NPI | 1508601675 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant |
| Enumeration Date | 2024-06-28 |
| Last Update Date | 2026-04-06 |