| NPI | 1154160612 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-15083) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2024-05-23 |
| Last Update Date | 2025-05-29 |