| NPI | 1861289761 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2025-04-23 |
| Last Update Date | 2025-04-23 |