| NPI | 1023700655 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-13381) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2023-05-23 |
| Last Update Date | 2025-04-22 |