| NPI | 1184162810 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110010445) |
| Additional Taxonomies | 225X00000X Occupational Therapist (Licence: NC 10248) |
| 363A00000X Physician Assistant (Licence: NC 0010-11169) | |
| 363AM0700X Physician Assistant, Medical | |
| Enumeration Date | 2017-02-01 |
| Last Update Date | 2026-08-19 |