| NPI | 1265027213 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA062514) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SC MPA.3891PA) |
| 363A00000X Physician Assistant (Licence: PA MA062514) | |
| Enumeration Date | 2021-03-02 |
| Last Update Date | 2025-07-21 |