| NPI | 1659259679 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9120662) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: FL PA9120662) |
| Enumeration Date | 2025-08-26 |
| Last Update Date | 2025-09-24 |