| NPI | 1013493998 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA100870) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA 60868441) |
| Enumeration Date | 2018-07-13 |
| Last Update Date | 2026-01-19 |