| NPI | 1114548492 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110007679) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C07941) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2020-04-28 |
| Last Update Date | 2025-01-08 |