| NPI | 1770770463 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA65987) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NJ 25MP00116800) |
| 363AS0400X Physician Assistant, Surgical (Licence: DE c5-0001203) | |
| Enumeration Date | 2007-09-27 |
| Last Update Date | 2025-10-09 |