| NPI | 1245702836 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NH EL31993) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA12512) |
| Enumeration Date | 2018-12-20 |
| Last Update Date | 2025-02-07 |