| NPI | 1346025913 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA 1203590) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO PA.0008932) |
| Enumeration Date | 2023-08-30 |
| Last Update Date | 2026-06-29 |