| NPI | 1790347292 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: AZ 7486) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 102912-875) |
| Enumeration Date | 2019-07-03 |
| Last Update Date | 2025-07-09 |