| NPI | 1124124771 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA054762) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0003856) |
| 363A00000X Physician Assistant (Licence: NC 104052) | |
| Enumeration Date | 2006-09-14 |
| Last Update Date | 2026-08-11 |