| NPI | 1700626652 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical |
| 363AM0700X Physician Assistant, Medical | |
| Enumeration Date | 2024-05-29 |
| Last Update Date | 2024-09-27 |