| NPI | 1720948078 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: WI 8721) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: WI 872123) |
| Enumeration Date | 2025-11-17 |
| Last Update Date | 2026-02-12 |