| NPI | 1558007955 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NE 2764) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NE pending) |
| Enumeration Date | 2022-05-09 |
| Last Update Date | 2023-03-01 |