| NPI | 1013549930 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 3664) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 12354) |
| Enumeration Date | 2020-02-08 |
| Last Update Date | 2025-10-01 |