| NPI | 1649813338 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9112608) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL 9112608) |
| Enumeration Date | 2019-10-24 |
| Last Update Date | 2025-07-15 |