| NPI | 1336782614 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C0007680) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363A00000X Physician Assistant (Licence: CA 62441) | |
| Enumeration Date | 2019-10-19 |
| Last Update Date | 2025-07-23 |