| NPI | 1154045672 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA064030) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA OA006262) |
| Enumeration Date | 2022-09-28 |
| Last Update Date | 2025-02-19 |