| NPI | 1154710077 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SD 1292) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 076565) |
| Enumeration Date | 2015-01-15 |
| Last Update Date | 2025-09-23 |