| NPI | 1730711151 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: GA 12988) | 
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9113011) | 
| Enumeration Date | 2020-02-05 | 
| Last Update Date | 2025-07-30 |