| NPI | 1336789767 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: AK 203147) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AK 203147) |
| Enumeration Date | 2020-01-14 |
| Last Update Date | 2025-10-27 |