| NPI | 1225764962 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID 4271493) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110008977) |
| Enumeration Date | 2022-07-26 |
| Last Update Date | 2026-01-19 |