| NPI | 1790311363 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: SC 6165) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 6165) |
| 363AS0400X Physician Assistant, Surgical | |
| 363A00000X Physician Assistant (Licence: NC 0010-009942) | |
| Enumeration Date | 2020-03-16 |
| Last Update Date | 2026-01-21 |