| NPI | 1215406830 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NE 2868) |
| Additional Taxonomies | 133V00000X Dietitian, Registered (Licence: NE 1283) |
| 133V00000X Dietitian, Registered (Licence: IA 090097) | |
| Enumeration Date | 2018-11-14 |
| Last Update Date | 2026-02-02 |