| NPI | 1194199349 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA066501) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 001006081) |
| Enumeration Date | 2015-11-25 |
| Last Update Date | 2025-10-31 |