| NPI | 1255404877 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA PA64999) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA3073) |
| 363A00000X Physician Assistant (Licence: MT 159579) | |
| 363A00000X Physician Assistant (Licence: GA 8941) | |
| Enumeration Date | 2006-11-15 |
| Last Update Date | 2025-07-07 |