| NPI | 1912743493 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: VA 0110010611) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA067191) |
| Enumeration Date | 2024-07-03 |
| Last Update Date | 2025-10-21 |