| NPI | 1063953164 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA6141) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CT 5059) |
| Enumeration Date | 2017-03-09 |
| Last Update Date | 2025-12-29 |