| NPI | 1669130373 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA OA007280) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: PA MA063264) |
| Enumeration Date | 2021-11-30 |
| Last Update Date | 2025-08-15 |