| NPI | 1780956946 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: PA MA058948) |
| Enumeration Date | 2012-02-03 |
| Last Update Date | 2025-01-28 |