| NPI | 1104783372 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-16367) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-16367) |
| Enumeration Date | 2026-01-08 |
| Last Update Date | 2026-03-12 |