| NPI | 1861114837 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-12570) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IN 10004375A) |
| 363AS0400X Physician Assistant, Surgical (Licence: NC 0010-12570) | |
| Enumeration Date | 2022-09-15 |
| Last Update Date | 2024-05-09 |