| NPI | 1104586098 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: DC PA200002358) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 10856) |
| Enumeration Date | 2021-12-20 |
| Last Update Date | 2026-04-27 |