| NPI | 1891984290 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: UT 5065151-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2007-10-22 |
| Last Update Date | 2026-05-01 |