| NPI | 1164151395 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 5659) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 122837) |
| Enumeration Date | 2022-06-04 |
| Last Update Date | 2025-02-27 |