| NPI | 1508699547 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9119340) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2024-08-23 |
| Last Update Date | 2025-04-02 |