| NPI | 1073397998 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: FL 9117778) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ND PAC1142) |
| Enumeration Date | 2023-08-22 |
| Last Update Date | 2025-03-05 |