| NPI | 1083793293 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 2210) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-00408) |
| Enumeration Date | 2006-11-06 |
| Last Update Date | 2025-04-13 |