| NPI | 1205390242 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA060568) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-11957) |
| 363A00000X Physician Assistant (Licence: SC 5531) | |
| Enumeration Date | 2019-01-23 |
| Last Update Date | 2026-03-06 |