| NPI | 1053042077 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 10010-14575) |
| Enumeration Date | 2022-06-21 |
| Last Update Date | 2025-11-20 |