| NPI | 1679823629 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110004012) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: VA 0110004012) |
| Enumeration Date | 2012-09-18 |
| Last Update Date | 2026-02-16 |