| NPI | 1902359573 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2025035589) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical |
| 363A00000X Physician Assistant (Licence: MA PA7877) | |
| 363A00000X Physician Assistant (Licence: FL PA9112225) | |
| Enumeration Date | 2016-07-29 |
| Last Update Date | 2025-09-03 |