| NPI | 1649555251 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110004224) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: VA 0110004224) |
| Enumeration Date | 2011-10-14 |
| Last Update Date | 2026-05-19 |