| NPI | 1023144193 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 5442) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 103090) |
| Enumeration Date | 2007-02-26 |
| Last Update Date | 2025-01-07 |