| NPI | 1821355454 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: OR PA218898) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN PA2126) |
| 363A00000X Physician Assistant (Licence: CO PA.0006653) | |
| Enumeration Date | 2012-04-20 |
| Last Update Date | 2025-06-17 |