| Specialty | Taxonomy Code | |
|---|---|---|
| * | Surgical | 363AS0400X |
| Medical | 363AM0700X | |
| Physician Assistant | 363A00000X |
* Indicates primary specialty
| NPI Number | 1174604359 |
| Credentials | PA (Physician Assistant) |
| Entity | Individual |
| Enumeration date | 10/17/2006 |
| Last updated | 09/11/2025 - About 9 months ago |
| Sole proprietor1 | No |
| Identifiers |
|
| Hospital affiliation | n/a |
1 A sole proprietor/sole proprietorship is an individual, and as such, is eligible for a single NPI number. The sole proprietor must apply for the NPI number using his or her own Social Security Number (SSN), not an Employer Identification Number (EIN) even if he/she has an EIN.
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