| NPI | 1316123359 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 12525) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110008196) |
| Enumeration Date | 2008-01-20 |
| Last Update Date | 2025-06-23 |