| NPI | 1346120052 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA066852) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: DE C5-0012347) |
| Enumeration Date | 2025-09-03 |
| Last Update Date | 2025-10-27 |