| NPI | 1265115547 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID 9071482) |
| Additional Taxonomies | 183700000X Pharmacy Technician (Licence: ID CT66258) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2023-08-11 |
| Last Update Date | 2025-10-27 |