| NPI | 1710792098 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: IA 130867) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NE 3250) |
| 363AS0400X Physician Assistant, Surgical (Licence: SD 1594) | |
| Enumeration Date | 2025-02-12 |
| Last Update Date | 2025-09-26 |