| NPI | 1922824796 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA065954) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA065954) |
| 363AS0400X Physician Assistant, Surgical (Licence: PA MA065954) | |
| Enumeration Date | 2024-11-26 |
| Last Update Date | 2025-03-13 |