| NPI | 1063226074 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AL 2876) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MS PA00872) |
| Enumeration Date | 2025-02-03 |
| Last Update Date | 2026-06-22 |