| NPI | 1063244929 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: PA MA065846) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MS9068227) |
| Enumeration Date | 2024-08-19 |
| Last Update Date | 2026-06-11 |