| NPI | 1184102162 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MT 69159) |
| Additional Taxonomies | 261QP2300X Clinic/Center, Primary Care (Licence: MT MED-PAC-LIC-69159) |
| Enumeration Date | 2018-08-01 |
| Last Update Date | 2026-07-21 |