| NPI | 1750718508 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-07625) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NC 0010-07625) |
| 363AS0400X Physician Assistant, Surgical (Licence: CT 2984) | |
| Enumeration Date | 2013-10-10 |
| Last Update Date | 2026-04-13 |