| NPI | 1528646874 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PR 3114) |
| Additional Taxonomies | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: TX 20-326) |
| Enumeration Date | 2021-03-30 |
| Last Update Date | 2026-05-11 |