| NPI | 1629474978 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 134292) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NC 001005368) |
| Enumeration Date | 2014-11-14 |
| Last Update Date | 2025-12-15 |