| NPI | 1164589651 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: PA MA055843) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA055843) |
| Enumeration Date | 2007-01-03 |
| Last Update Date | 2025-07-21 |