| NPI | 1821980657 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PR 002698P.A.) | 
| Additional Taxonomies | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: FL 24-208) | 
| Enumeration Date | 2025-07-16 | 
| Last Update Date | 2025-07-20 |