| NPI | 1255040564 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-12992) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2022-11-16 |
| Last Update Date | 2026-08-12 |