| NPI | 1740037951 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9118789) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: FL PA9118789) |
| Enumeration Date | 2024-05-06 |
| Last Update Date | 2026-02-10 |