| NPI | 1033582606 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-13899) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL 9109211) |
| Enumeration Date | 2015-11-04 |
| Last Update Date | 2025-08-05 |