| NPI | 1700136587 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9120236) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: CT 002845) |
| Enumeration Date | 2012-09-19 |
| Last Update Date | 2025-06-26 |