| NPI | 1568955441 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9120288) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AR PA-790) |
| 363A00000X Physician Assistant (Licence: SC 3352) | |
| Enumeration Date | 2018-06-14 |
| Last Update Date | 2025-07-14 |