| NPI | 1114956190 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MT 444) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2006-07-01 |
| Last Update Date | 2026-06-26 |