| NPI | 1760182372 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-13100) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363AS0400X Physician Assistant, Surgical (Licence: NC 0010-13100) | |
| Enumeration Date | 2023-03-03 |
| Last Update Date | 2023-03-06 |