| NPI | 1619749082 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: PA MA064884) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: PA OA006668) |
| Enumeration Date | 2023-10-27 |
| Last Update Date | 2023-10-27 |