| NPI | 1669859468 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PR 3046) |
| Additional Taxonomies | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: FL 15-308) |
| 363AM0700X Physician Assistant, Medical (Licence: PR 3046) | |
| 363AS0400X Physician Assistant, Surgical (Licence: PR 3046) | |
| Enumeration Date | 2015-04-30 |
| Last Update Date | 2026-04-28 |