| NPI | 1356943484 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TN 6589) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 10263) |
| Enumeration Date | 2020-11-13 |
| Last Update Date | 2026-02-05 |