| NPI | 1114652559 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-12945) |
| Enumeration Date | 2022-07-20 |
| Last Update Date | 2025-04-07 |