| NPI | 1992235204 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA6427) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MA PA6427) |
| Enumeration Date | 2017-06-19 |
| Last Update Date | 2025-08-13 |