| NPI | 1386201440 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: ID PA-1816) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 9697) |
| 363A00000X Physician Assistant (Licence: WA PA61125209) | |
| Enumeration Date | 2019-05-23 |
| Last Update Date | 2025-10-31 |