| NPI | 1568945004 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9113032) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: CT 4269) |
| Enumeration Date | 2018-09-11 |
| Last Update Date | 2025-03-12 |