| NPI | 1033967245 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA100978) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2024-05-11 |
| Last Update Date | 2025-08-22 |