| NPI | 1811624976 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9120303) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: GA 11114) |
| Enumeration Date | 2022-08-08 |
| Last Update Date | 2026-03-13 |