| NPI | 1225326440 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA OA007126) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA055025) |
| Enumeration Date | 2011-07-21 |
| Last Update Date | 2025-01-16 |