| NPI | 1225079189 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 55753) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY PA3658) |
| 363A00000X Physician Assistant (Licence: TX PA02417) | |
| Enumeration Date | 2006-06-09 |
| Last Update Date | 2026-02-07 |