| NPI | 1285342451 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-12892) |
| Enumeration Date | 2022-11-07 |
| Last Update Date | 2025-08-20 |