| NPI | 1164283529 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID 1971664) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2024-01-22 |
| Last Update Date | 2025-09-02 |