| NPI | 1295498210 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 6460) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: AZ 9437) | |
| Enumeration Date | 2021-10-17 |
| Last Update Date | 2025-09-02 |