| NPI | 1578197653 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 4080) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: TN 4080) |
| Enumeration Date | 2020-02-27 |
| Last Update Date | 2025-03-05 |