| NPI | 1053493239 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA052598) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NH 2955) |
| Enumeration Date | 2006-10-19 |
| Last Update Date | 2025-02-25 |