| NPI | 1669259131 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-2736) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: ID PA-2736) |
| 363AM0700X Physician Assistant, Medical (Licence: ID PA-2736) | |
| Enumeration Date | 2023-09-11 |
| Last Update Date | 2025-12-30 |