| NPI | 1174344949 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA066135) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: PA MA066135) |
| Enumeration Date | 2024-10-23 |
| Last Update Date | 2025-03-20 |