| NPI | 1083962971 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 001010441) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC 1817) |
| Enumeration Date | 2012-08-27 |
| Last Update Date | 2025-02-05 |