| NPI | 1972787695 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CA PA19457) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NV PA1413) |
| Enumeration Date | 2007-12-18 |
| Last Update Date | 2025-04-08 |