| NPI | 1376694737 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA-1151) |
| Enumeration Date | 2007-01-14 |
| Last Update Date | 2025-07-24 |