| NPI | 1699028803 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NCCPA # 1107262) |
| Enumeration Date | 2012-10-25 |
| Last Update Date | 2025-02-04 |