| NPI | 1922985258 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PR 3045) |
| Additional Taxonomies | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: FL 25-363) |
| 363AS0400X Physician Assistant, Surgical (Licence: PR 3045) | |
| Enumeration Date | 2025-08-19 |
| Last Update Date | 2026-05-02 |