| NPI | 1306681473 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SC 5962) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA065636) |
| Enumeration Date | 2024-06-28 |
| Last Update Date | 2025-09-02 |