| NPI | 1376063214 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NE 2996) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical |
| Enumeration Date | 2017-06-21 |
| Last Update Date | 2025-01-08 |