| NPI | 1790310449 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CA PA66810) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: TX PA14405) |
| Enumeration Date | 2020-03-03 |
| Last Update Date | 2025-07-24 |