| NPI | 1942789151 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical |
| 261QV0200X Clinic/Center, VA | |
| Enumeration Date | 2018-08-08 |
| Last Update Date | 2023-08-31 |