| NPI | 1194148833 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110004380) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-04776) |
| Enumeration Date | 2014-01-31 |
| Last Update Date | 2025-10-15 |