| NPI | 1235196965 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C0003053) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: DE C5-0012131) |
| Enumeration Date | 2006-04-27 |
| Last Update Date | 2025-01-22 |