| NPI | 1316311178 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-08038) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MA PA5571) |
| Enumeration Date | 2015-11-17 |
| Last Update Date | 2025-04-01 |