| NPI | 1053148965 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: MD C0009970) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2024-09-16 |
| Last Update Date | 2025-06-17 |