| NPI | 1679186480 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 13362830-1206) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WY PT972) |
| Enumeration Date | 2020-08-31 |
| Last Update Date | 2023-07-21 |