| NPI | 1689458572 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 122028) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: IA 122028) |
| 363AS0400X Physician Assistant, Surgical (Licence: IA 122028) | |
| Enumeration Date | 2023-08-22 |
| Last Update Date | 2025-04-24 |